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| |  Measuring Levels of Procalcitonin Can Reduce Unnecessary Antibiotic Use in ICU NEW YORK -- January 22, 2010 -- Measuring levels of the biomarker procalcitonin in people in intensive care gives an accurate indication of the severity of bacterial infection they are experiencing. This in turn gives a clear indication as to the nature and length of any antibiotics course they require, according to a study published early online and appearing in an upcoming edition of The Lancet. Michel Wolff, MD, Hôpital Bichat-Claude-Bernard, Paris, France, and colleagues suggest that by using procalcitonin levels to prescribe antibiotics rather than the current arbitrary guidelines, people’s exposure to antibiotics could be decreased, and hopefully the increasing rate of antibiotic resistance can be slowed. Guidance about blood procalcitonin concentration has substantially reduced antibiotic use in patients presenting to the emergency department or admitted to hospital for lower-respiratory-tract infections. Despite these encouraging results, the potential usefulness of procalcitonin as an instrument to guide antibiotic use in all intensive care units has not yet been shown. In this study, the authors looked at the effectiveness of using procalcitonin to reduce antibiotic exposure in intensive care. In the randomised controlled trial, patients were assigned in a 1:1 ratio to procalcitonin (n = 311) or control (n = 319) groups. For the procalcitonin group, antibiotics were started or stopped based on predefined cut-off ranges of procalcitonin concentrations; the control group received antibiotics according to present guidelines. Drug selection and the final decision to start or stop antibiotics were at the discretion of the physician. Patients were expected to stay in the intensive care unit for more than 3 days, had suspected bacterial infections, and were aged 18 years or older. Primary endpoints were mortality at days 28 and 60, and number of days without antibiotics by day 28. Nine patients were excluded from the study; 307 patients in the procalcitonin group and 314 in the control group were included in the final analyses. Mortality of patients in the procalcitonin group seemed to be no worse than the control group at day 28 (21% vs 20%) and day 60 (30% vs 26%). Patients in the procalcitonin group had almost 3 more days without antibiotics by day 28 (14.3 days vs 11.6 days). The authors pointed out that, despite lower antibiotic exposure in the procalcitonin group than in the control group, they were unable to show a between-group difference for the rates of emerging multidrug-resistant bacteria. “Nonetheless, we stress that infection is the tip of the iceberg compared with digestive colonisation,” the authors said. “Rectal, nasal, and axillary swab screening was not routinely done and might more accurately show antibiotic selective pressure. Moreover, a 3-day reduction of antibiotic use for only a small subset of admitted patients might not be sufficient to record a decreased resistance-emergence rate, especially for some intensive care units with high cross-transmission rates.” “The diverse clinical characteristics and reasons for admissions to the intensive care unit for patients enrolled in this study suggest that our conclusions could be applicable to most non-surgical patients in the intensive care unit, including those who are immunocompromised,” the authors concluded. “A procalcitonin-guided strategy could reduce antibiotic selective pressure with potential benefits in the era of multiresistance.”
SOURCE: The Lancet
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